Alz.org
Sample Letter Instructions (Sections marked in bold are mandatory)
Date: MM/DD/YYYY (within the past 12 months)
To: National Finance Center
Pre-Existing Condition Insurance Plan
P.O. Box 60017
New Orleans, LA 70160-0017
From: Name of Doctor, Physician Assistant, or Nurse Practitioner
Address: (Unless in Letterhead/Footer)
License #: License number of Doctor, Physician Assistant, or Nurse Practitioner
State of Licensure:
Subject: Patient’s Name, DOB
To Whom It May Concern,
For the purpose of qualifying for the Pre-Existing Condition Insurance Program (PCIP), please find this letter as confirmation that (Patient’s Name) has or had the following pre-existing condition(s) within the past 12 months:
If you require any clarification, please contact me via the following phone number:
XXX-XXX-XXXX
Sincerely,
Signature of Doctor, Physician Assistant, or Nurse Practitioner
................
................
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